Over the past decade or so, the global aviation industry has come to realize that pointing the finger of blame at one of our own for a mistake does nothing to identify the real problem at hand. The only exception to ignoring the why behind an incident or accident is when a person is found to be criminally negligent, in other words, the person’s actions were not accidental.
Safety management systems (SMS), now required for most Part 121 airlines and commercial airports, have had great success at identifying potential operational risks. One key to this success has been the creation of a Just Culture designed to identify the root cause of the incident or accident. When employees make an honest mistake, they can fess up while not worrying they’ll lose their job or spend time behind bars. More and more employees are sharing details of their mistakes because they know their admissions can help save lives.
The world of air traffic control has been an integral part of aviation’s Just Culture community since the beginning, although recently, the world was reminded that not every country subscribes to the value of the Just Culture philosophy.
Last month, a Swiss air traffic controller, an employee of Skyguide, that country’s air navigation service provider, was found guilty of a negligent disruption of public transport for an incident that occurred at Zurich Airport in September, 2012. In the 2012 incident, a commercial aircraft operated by Darwin Airline took off while a private sports aircraft on a training flight was on approach. No details of the distances between the aircraft involved were released. In April and October of 2018, two additional air traffic controllers were, “convicted by the Swiss Federal Penal Court and by the Cantonal Court of Zurich respectively for operational incidents. Switzerland is a signatory member of the International Civil Aviation Organization (ICAO) that has pushed hard for extending the Just Culture philosophy in search of data to improve aviation industry safety around the world.
In a March 2011 incident, ” … two aircraft received takeoff clearance, one shortly after the other, at Zurich Airport and began their takeoffs on the airport’s intersecting Runway 16 and Runway 28. The aircraft on Runway 16 departed as planned, while the aircraft on Runway 28 aborted its takeoff roll. The incident did not result in harm or damage to persons or property. The involved air traffic controller actively reported the incident and thereby contributed to clarify the circumstances of the incident. criminal proceedings were initiated against the air traffic controller on duty, who appeared at the Bülach District Court in December 2014 and April 2016 charged with disruption of public traffic, where he was acquitted,” the sUAS News reported.
In none of these incidents was there an reported injuries or damage to the aircraft or the ground infrastructure,” according to Air Traffic Management. Here in the U.S., the incidents reported in Switzerland would have been labeled as close calls, with controllers possibly seeing some time off pending additional training in search of the cause.
The National Air Traffic Controllers Association (NATCA), the union for U.S. air traffic controllers yesterday joined the International Federation of Air Traffic Controller’s Association (IFATCA) and the European Cockpit Association in expressing extreme disappointment about these convictions. “Switzerland remains one of the few nations that has chosen to deviate from internationally accepted standards of safety culture when it comes to using safety reports to trigger criminal prosecution,” NATCA said in a news release. “NATCA joins IFATCA and the 38,000 pilots represented by ECA in urgently calling upon Switzerland to align with international standards other states’ laws incorporating just culture principles into its legal system in order to provide for a balanced approach between safety and the administration of justice.
“The implementation of a safety culture that continually strives to improve safety within the air traffic control system and the larger aviation industry, with collaborative safety programs, results in a safer system. These results have been demonstrated thousands of times over during the past decade here in the United States. NATCA and the Federal Aviation Administration (FAA) have a very successful voluntary, non-punitive reporting program for controllers and supervisors to proactively improve safety by identifying safety concerns we may have otherwise not known about.
This program, called the Air Traffic Safety Action Program (ATSAP), has grown into the largest and most successful voluntary reporting program of its kind with over 165,000 reports filed since being deployed nationwide in 2010, an average of 17,000 per year. NATCA and the FAA also participate in multiple safety programs and initiatives that include government and aviation industry stakeholders, which serve as conduits for the sharing of critical safety information and the identification of safety trends … we have moved away from the blame culture and embracing the just culture and the learning culture. Our hope for Switzerland and the other nations that deviate from these principles and international standards is that they can learn from the positive examples of a safety culture in order to improve their own systems.”
